When Anne Soloviev went to Braun Dermatology and Skin Cancer Center in Washington, D.C., for her semiannual dermatology checkup in early January, the physician assistant diagnosed fungus in two of her toenails.
Soloviev hadn't complained about her toenails or even noticed a problem.
But the physician assistant offered a solution anyway. She called in a prescription for an antifungal medicine to a specialty pharmacy with mail-order services that would send it to Soloviev's Capitol Hill home.
It seemed like an easy fix to an inconsequential health issue. "I did not ask how much it cost — it never crossed my mind, ever," said Soloviev, a former French teacher, who still works part time.
Then the bill came.
Patient: Anne Soloviev, 76, of Washington, D.C.
The bill: $1,496.09 for Kerydin, a topical medication that treats toenail fungus. Originally produced by Anacor Pharmacueticals, the drug is now a product of Sandoz, a division of Novartis.
Service provider: My Express Care Pharmacy, plus Braun Dermatology and Skin Cancer Center
Medical treatment: The antifungal medicine arrived by overnight mail, and an automatic refill came a few weeks later. She began using it on the two toenails, as directed, having been told it would take about 11 months to treat her feet.
She thought little of it.
Soloviev, a widow, has robust insurance. She is covered by Medicare, parts A and B, and has supplemental insurance through her late husband's government health benefits that covers prescription drugs. She also has a health reimbursement account, which receives almost $1,500 pre-tax each year to pay for uncovered medical expenses. She typically uses the HRA money to cover copays for the other medicines she takes regularly.
But when Soloviev went to her local CVS to pick up another medication — a cholesterol-lowering statin that is usually paid for by her HRA — she discovered her reserve was empty.
Unbeknownst to her, the Kerydin charges had wiped out her entire health reimbursement account.
What gives: According to Leslie Pott, Sandoz vice president of communications, Kerydin is patent-protected and priced "at parity" with its one market competitor, Jublia. She also pointed out that to secure a place on an insurer's list of approved drugs — its formulary — the company often had to offer substantial discounts to insurers and various middlemen. "We have no visibility into the extent to which these discounts are passed onto patients or payers," she wrote in an email.
In the application for Food and Drug Administration approval granted in 2014, Anacor Pharmaceuticals highlighted that a year-long treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial and in 9.1 percent of patients in another.
There are many treatment options for toenail fungus — both older medicines in pill form and newer topical treatments such as Kerydin, said Dr. Shari Lipner, an assistant professor at Weill Cornell Medicine in New York and director of its nail unit. The patient in this case would have been a candidate for "quite a few" of them.
Patients are likely to pay less for the pills, she said, and they also seem to have greater efficacy. Health plans also are less likely to cover the newer treatments, such as Kerydin. If they do, they often require patients to try the less expensive options first.
After a proper diagnosis based on a nail clipping or scraping, Lipner said, patients should be offered all the options and be counseled about their proper use. For example, the oral treatments usually last three months while the topical medicines must be used for a year. And, especially for the newer ones, like Kerydin, insurance coverage can be limited. Cost is likely to be something patients will want to consider, Lipner said.
Xavier Davis, Braun Dermatology and Skin Cancer Center's practice manager, said a drug's price tag simply isn't a factor when prescribers recommend a course of treatment.
"When our providers are treating patients, we're not treating them based on what the cost's going to be. We look for what's the best care for the patient," Davis said. "If the patient calls and says that's too expensive, then we'll look for alternatives."
But patients often don't see the actual price until it's too late.
In January, Soloviev's insurance plan was billed the full price of Kerydin. Of that, $1,439.57 came from her HRA. The difference, $56.52, was covered by a patient-assistance program from the drug manufacturer, explained Jonathan Lee, a pharmacist for My Express Care.
In February, when her prescription was refilled, Soloviev's plan was again billed the full price. But she didn't know about that either. A manufacturer coupon was applied to cover what remained of her insurer's $2,000-annual deductible and the $60 copay. Her insurance then kicked in to pay the difference.
CVS Caremark, the pharmacy benefit manager that administers the drug coverage for Soloviev's plan, said it was structured to pay for such an expense automatically, using the HRA. Had the HRA been structured differently, the coupon may have covered more of the costs upfront, said company spokeswoman Christine Cramer.
Meanwhile, Lee, the pharmacist, said even he didn't realize that money could be withdrawn directly from a patient's HRA without her knowledge.
"I just find it is outrageous for a fungal medicine to cost $1,400, to be prescribed for 11 months, and for neither the P.A. nor the pharmacy to warn you," Soloviev said.
Resolution: Although Soloviev told My Express Care not to renew the prescription, her HRA is depleted. For the rest of the year, she'll have to pay out-of-pocket costs for any other medications, an expense she hadn't planned on.
The takeaway: Medical professionals should talk with patients about the options for treatment and what the costs will be. That is especially true if they are recommending a high-priced medicine.
Patients should take nothing for granted and ask about the cost of every new prescription. And, because costs can vary depending on coverage, they may need to contact their insurance carrier or the pharmacy benefits manager that handles their medicine claims. Finally, patients should ask again at the pharmacy – even if that means calling a mail-order pharmacy. It never hurts to ask whether there are generic or over-the-counter alternatives.
This is a monthly feature from Kaiser Health News and NPR that dissects and explains real medical bills to shed light on prices in U.S. health care and to help patients learn how to be more active in managing costs. Do you have a medical bill that you would like us to see and scrutinize? Submit it here and tell us the story behind it.
LULU GARCIA-NAVARRO, HOST:
Sometimes, small complaints can trigger absurdly large medical bills. We're joined now by Dr. Elisabeth Rosenthal, editor-in-chief of our partner Kaiser Health News, to talk about a bill to treat a toenail fungus and what happened next. Welcome to the program.
ELISABETH ROSENTHAL: Thanks for having me.
GARCIA-NAVARRO: The bill we're talking about is $1,469 for medication for a woman here in Washington, D.C. Tell me the story.
ROSENTHAL: Well, Anne Soloviev went to her dermatologist just for a skin check. She didn't even realize she had a toenail problem. And the physician assistant who saw her said, oh, you have toenail fungus. Let us call in a prescription. And she thought, yeah, sure. Why not.
GARCIA-NAVARRO: Not a big deal.
ROSENTHAL: It wasn't bothering me, but why not treat it? That's where the trouble began.
GARCIA-NAVARRO: So she didn't know the cost of the medication, right?
ROSENTHAL: No. She didn't ask, and the physician assistant didn't tell. So the PA calls in the prescription to a mail-order pharmacy. The mail-order pharmacy calls Anne to say, what's your insurance? She tells them she has really good insurance, and she has a health savings account or health reimbursement account to cover all of those medical costs that her insurance doesn't cover.
GARCIA-NAVARRO: So she's very well-covered.
ROSENTHAL: She's golden. She shouldn't have a problem here. But she discovers belatedly that this prescription for toenail fungus is almost $1,500 a month.
ROSENTHAL: And she's supposed to be using it for 11 months. And the problem is the first month of this prescription alone had drained her health savings account to nothing, unbeknownst to her.
GARCIA-NAVARRO: All right. Let's pick this apart a little bit because I'm assuming that there were other ways to treat this particular complaint that might not have been so astronomically expensive.
ROSENTHAL: Yes, there are a wide array of choices for people with mild toenail fungus.
GARCIA-NAVARRO: And at no point did the doctor or anyone say, these are the alternatives. This is what it costs.
ROSENTHAL: No. All it was was here's something you could use. Put it on for the next 11 months. We'll call in the prescription. It'll take care of it. Don't worry.
GARCIA-NAVARRO: Did you reach out to the doctor's office and to the pharmacy to find out why?
ROSENTHAL: We reached out to everyone. And basically, they said, as so many doctors are want to say, we don't think about price when we prescribe. We just want to give, you know...
GARCIA-NAVARRO: The best thing that's out there.
ROSENTHAL: The best. But I'd have to say in this case there's not even proof that this is the best. In the studies that got this drug approved, this drug was only effective in curing toenail fungus from 6 to about 9 percent of the time after 11 months of treatment. So it's not even a very effective drug.
GARCIA-NAVARRO: From your reporting on this, though, why do doctors do this? They say it's not about cost, but is there an ulterior motive - something that makes certain doctors push certain medicines?
ROSENTHAL: Yeah. I think it's very complicated, and it's different in each case. In some cases, doctors have financial relationships with pharmaceutical companies. We actually looked in this case, and we didn't find any. But I think a lot of it is kind of willful ignorance - like it's not important to them. And they didn't do their due diligence before prescribing it to patients - would be my take on what happened.
GARCIA-NAVARRO: Is there any recourse for Anne?
ROSENTHAL: This year, no. In fact, when she called the pharmacist to say this happened, you know, this one prescription drained my HSA. And she said, and I'm going to report this to bill of the month. The pharmacist said, I hope NPR can help you.
GARCIA-NAVARRO: We want to see more bills, whether they're unusually high or just interesting. If you'd like to participate and have Dr. Elisabeth Rosenthal do some digging around, please go to NPR's Shots blog. That's npr.org/shots. Thank you so much.
ROSENTHAL: Thanks for having me.
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